PHINMA EDUCATION NETWORK

College of Nursing

NUR 106: CARE OF CLIENTS WITH PROBLEMS IN OXYGENATION, FLUID AND

ELECTROLYTE, INFECTIOUS, INFLAMMATORY AND
IMMUNOLOGIC RESPONSE, CELLULAR ABERRATION,
ACUTE AND CHRONIC

WOUND DRESSING
EQUIPMENT
● Sterile Gloves
● Variety of gauze dressings and pads
● Irrigation kit
● Cleaning solution
● Sterile solution: water, normal saline, sodium hypochlorite (Dakin’s solution)
● Clean, disposable gloves
● Tape, ties, bandage as needed
● Waterproof pad and bag
● Extra gauze dressings
● Montgomery ties; elastic net
● Mask, goggles, or gown for risk of splashing
ASSESSMENT: SCRIPT
1. Identify patient using two identifiers Nurse: “Good morning, I am Jenna your nurse
(e.g., name and birthday or name and medical this shift from 8am-4pm. I am going to change
record number) your wound dressing. But before we proceed, I
would like to know some details. What is your
Rationale: complete name?
Ensures correct patient
Patient: My full name is Maria Dela Cruz.
2. Review medical record for information about Nurse: Thank you Maria, upon checking your
size and location of wound medical record your wound is located at the right
side of your leg. Can you show me your right leg?
Rationale:
Provides baseline to compare your findings. Helps Patient: (showing her right leg)
to plan for proper type and number of supplies
needed. Alerts you when help is needed to hold
dressings in place

3. Assess patient’s level of comfort using a scale of Nurse: Can you tell me how much pain do you
0-10. feel right now? From the scale of zero as the
lowest pain scale and 10 is the highest.
Rationale:
Removal of dry dressing is painful: some patients Patient: 6 out of 10
require pain medication.

4. Review orders for dressing change procedure Nurse: I see, let me check the chart to verify the
doctor’s order and start changing you wound
Rationale: dressing. Do you have any allergies to certain
Indicates type of dressing or applications use. agents or tape?
5. Assess patient for allergies to wound cleansing
agents or tape Patient: I don’t have any allergies to any agent or
tape.
Rationale:
Prevents adverse reactions.

6. Assess patient’s and family’s knowledge of Nurse: What are the ways you do whenever
purpose and steps of dressing change you’re in pain?

Rationale: Patient: I usually elevate my leg and position in a

Determine specific areas for patient and family way that I feel comfortable.
teaching.

7. Assess for risk of delayed or poor wound Nurse: Okay, that’s better. Within this week, did
healing notice any bleeding or discharge?

Rationale: Patient: I don’t notice any bleeding or discharge. I

Physiological changes and effects of disease and have a feeling that it is recovering.
treatment conditions can affect wound healing.

PLANNING SCRIPT
8. Explain procedure to patient and instruct him or Nurse: The goal of wound irrigation is to remove
her not to touch wound area or sterile supplies foreign material, decrease bacterial contamination
of the wound, and in addition, may I advise you to
Rationale: avoid touching your wound site or any other sterile
supplies.
Decreases anxiety

9. Position patient comfortably and drape with Nurse: I will placed you Mam/Sir on your
blanket to expose only wound site. comfortable position with a drape blanket
exposing only the wound site.
Rationale:
Provides access to wound yet minimizes
unnecessary exposure

10. Plan dressing change 30-60 minutes following Nurse: I will change your dressing every 30 - 60
administration of analgesia. minutes following the administration of analgesia
Rationale:
Allows for peak action of medication so patient so
patient has optimal level of comfort during dressing
change. Patients tolerate dressing changes when
their pain is controlled.

IMPLEMENTATION SCRIPT/RATIONALE
11. Close room door or pull bedside curtains. Provides privacy and reduces transmission of
Perform hand hygiene and apply gloves microorganism

12. Position patient comfortably and drape only to Nurse: I am going to placed you Mam on your
expose wound site. comfortable position exposing only your wound
area.
Rationale:
Draping provides access to wound while
minimizing unnecessary exposure.
13. Place disposable bag within reach of work Ensures easy disposable of soiled dressings.
area. Prevents soiling of outer surface of bag.

14. Remove tape: gently push skin away from tape Nurse: Mam I will remove the tape on your wound
while pulling adhesive from skin. gently, tell me if you feel any pain.
Rationale:
Push- pull technique releases tape from skin,
reducing chance of skin damage.

15. With gloved hand carefully remove gauze Nurse: I am going to moisten the gauze using
dressings one layer at a time, taking care not to saline solution,and I will remove the gauze
dislodge drains or tubes. carefully and slowly, then take a deep breathe,
inhale and exhale .
a. If dressing sticks on dry dressing, moisten with
saline and the remove
Rationale
Removal of one layer at a time reduces chance of
accidental removal of underlying drains.
Prevents damage to wound tissue.

16. Observe for wound for color, edema, drains Provides estimate of drainage amount and
and exudates and amount of drainage on dressing assessment of condition of wound.

17. Fold dressings with drainage contained inside Reduces transmissions of microorganism.
and remove gloves inside out. With small Prevents contact of hands with material on gloves.
dressings remove gloves inside out over dressing.
Dispose of gloves and soiled dressings in
disposable bag. Perform hand hygiene

18. Open sterile dressing tray or individually Sterile dressings remain sterile while on or within
wrapped sterile supplies. Place on bedside table sterile surface. Preparation of supplies prevents
and apply clean gloves break in technique during dressing change.

19. Clean wound with solution. Using gauze or Nurse: Mam, using an antiseptic swab or septic
antiseptic swab, clean from least contaminated solution we will clean your wound, this is to
area, which is the incision and surrounding skin. prevent contamination and the spread of infection
Dry area. Remove and dispose of gloves and at your incision site.
perform hand hygiene.
Rationale:
Prevents contamination of previously cleaned
area. Reduces transmission of infection.

20. Apply dressing Allows handling of sterile supplies without

a. Dry dressing contamination.
1. Apply clean or sterile gloves. Once wound is clean you are able to better inspect
2. Inspect wound for appearance, drains, drainage wound condition. Indicates status of wound
and integrity. healing.
3. Apply sterile, loose woven gauze (4x4, 2x2) dry Protects wound from external environment.
dressing, covering wound.
Apply additional gauze as needed.

21. Secure dressing Goal for securing dressing is to keep dressing in

a. Tape: apply tape 2.5-5 cm (1-2 inches) beyond place and intact without causing damage to
dressing, use non allergic tape to underlying and surrounding skin.
secure dressing in place.
 b. Montgomery ties Secure dressing. Reduces sensitivity reaction to
1. Open by exposing adhesive surface tape.
tape on end of each tie.
2. Place ties on opposite sides of Ties allow for repeated dressing changes
dressing. without the need for tape removal and
3. Place adhesive directly on skin or apply a solid subsequent skin and tissue damage.
skin barrier to skin and secure end of tape on skin Solid skin barrier protects intact skin from
barrier. stench and tension of adhesive tape.
4. Secure dressing by lacing ties across it
5.. For dressings on extremity, secure dressing with
rolled gauze or elastic net.

22. Remove gloves and dispose of them in bag. Reduces transmission of infection.
Remove any mask, eyewear or gown

23. Write date and time dressing applied in ink on Provides guide for when to perform next
tape securing dressing dressing change.

24. Help patient to comfortable position. Improves patient comfort.

25. Dispose of supplies and perform hand hygiene Reduces transmission of infection.
EVALUATION SCRIPT
26. Inspect condition of wound and any drainage. Nurse: “We are almost done. Let me now check
and evaluate your wound dressing for any
Rationale: leakage or drainage.”
Determines rate of healing
27. Ask patient to rate level of pain during and after Nurse: “Can you tell me how much pain do you
the procedure. feel right now? From the scale of zero as the
lowest pain scale and 10 is the highest.
Rationale:
Pain is early indicator of wound complications or Patient: “5 out 10”
result of dressing material pulling underlying tissue.

28. Inspect condition of dressing and note any Nurse: “I see, I will take note and document
observable drainage every shift. including the current condition. Besides, I will
come here to visit and recheck your wound
Rationale: every 3-4 hours to check on you and your
Determines status of wound drainage. wound. Thank you, Maria. See you later.

WOUND IRRIGATION PROCEDURE

ASSESSMENT: SCRIPT

1. Identify patient using two identifiers (e.g., name Good morning/afternoon Ma’am/Sir! My
and birthday or name and medical record number) name is Jasper, and I will be your nurse for
according to agency policy. today. But before we proceed, I would like to
know some details. What is your complete
Rationale: name?
Ensures correct patient.

2. Assess patient’s level of pain. How do you feel right now? Do you feel any
pain? From the scale of zero as the lowest pain
Rationale: scale and 10 is the highest.
Provides baseline to measure patient’s response to
therapy. Discomfort is related directly to wound or
indirectly to muscle tension or immobility.

3. Review medical record for health care provider’s I will check your medical records for the
prescription for irrigation of open wound and type of irrigating prescription solution
solution

Rationale:
Open wound irrigation requires medical order,
including type of solution to use.

4. Review medical record for signs and symptoms Do you feel any untoward signs and
related to patient’s open wound. symptoms concerning your wounds?

Rationale: I will assess your wound site and please tell

Data provide baseline to indicate change in me if you feel any pain during the assessment
condition of wound.

a. Extent of impairment of skin integrity, including

size of wound. (Measure length,
width, and depth in centimeters in the ff.
order: length, width, and depth.)
Rationale:
Assess volume of irrigation solution needed. Data
also used as baseline to indicate change in
condition of wound.

b. Verify number and types of drains present.

Rationale:
Awareness of drain placement facilities safe
dressing removal and identifies type and quantity of
new dressings needed. Expect amount to decrease
as healing takes place.
c. Drainage from wound (amount and color) (Amount
can be measured by part of
dressing saturated on in terms of quantity
e.g., scant, moderate, copious
Rationale:
Serious drainage is clear like plasma: sanguineous
or bright red drainage indicates fresh bleeding;
serosanguineous drainage is pink. Purulent
drainage is thick and yellow, pale, green or white

d. Odor (must state whether or not there is odor)

Rationale:
Strong odor indicates infection process.

e. Wound tissue color

Rationale:
Color represents balance between necrotic tissue
and new scar tissue.

f. Conistency of drainage
Rationale:
Type of color of drainage depend on moisture of
wound and type of organism present.

g. Culture reports
Rationale:
Chronic wounds heal by secondary intention, and
they are often colonized with bacteria.

h. Condition of dressing: dry and clean; evidence of

bleeding, profuse drainage.
Rationale:
Provides initial assessment of presentwound
drainage.

PLANNING: SCRIPT

1. Explain procedure of wound irrigation and Wound irrigation is a non-invasive procedure

cleaning how you will prepare patient. in which a steady flow of a solution is used
to achieve wound hydration; remove debris,
Rationale: dead cells, pathogens, and excess blood or
Reduces patient’s anxiety. other exudates such as pus in an open
wound; and assist with a better visual
examination

2. Administer prescribed analgesic 30-60 minutes 30 minutes to 1 hour before we start irrigating
before starting wound irrigation procedure. the wound, administering prescribed analgesic
Rationale: would help to control the pain level and could
Promotes pain control and permits patient to move help you move easily
more easily and be positioned to facilitate wound
irrigation.

3. Position patient to access wound for easy I will placed you Mam/Sir on your
irrigation. comfortable position during irrigation
a. Position comfortably so wound is vertical to
collection basin, which permits gravitational flow of
irrigating solution
through wound and into collection receptacle.
Rationale:
Directing solution from top to bottom of
wound and from clean to contaminated
area reduces spread of infection. Position
patient, keep in mind bed surfaces needed for later
preparation equipment.

b. Place container of irrigant/cleaning solution in

basin of hot water to warm
solution to body temperature.
Rationale:
Warmed solution increases comfort and
reduces vascular constriction response in tissues.

c. Place padding or extra towel in bed

Rationale:
Protects bedding.

IMPLEMENTATION:

1. Perform hand hygiene. Reduces transmission of microorganism.

2. Form cuff on waterproof bag and place it near Cuffing helps to maintain large opening, thereby
bed. permitting placement of contaminated dressing
without touching refuse bag itself.

3. Close room door or bed curtains. Maintains privacy

4. Apply gown, mask, goggles if needed. Protects nurse from splashes or sprays of blood
and body fluids

5. Apply clean gloves and remove soiled dressing Reduce transmission of microorganism
and discard waterproof bag. Discard gloves and
perform hang hygiene.

6. Prepare equipment: open sterile supplies

7. Put on clean or sterile gloves Reduce transmission of microorganism

8. To irrigate wound with wide opening: Flushing wound helps remove debris and
a. Fill 35-ml syringe with irrigating solution. b. facilitates healing by secondary intention.

Attach soft 19-gauge Angio catheter. Provides ideal pressure for cleaning and
removing debris.
c. Hold syringe tip 2.5 cm (1 inch) above upper end
of wound and over area being Prevents syringe contamination.
cleaned.

d. Using continuous pressure, flush wound: repeat

Steps 8a, b, and c until solution Clear solutions indicates that you have
draining into basin is clear. removed all debris.

9. To irrigate deep wound with very small opening:

a. Attach soft 19-gauge Angio catheter to filled Catheter permits direct flow of irrigant into
irrigating syringe. wound. Expect wound to take longer to empty
when opening is small.

b. Gently insert tip of catheter into wound and pull Removes tip from fragile inner wall of
out about 1 cm (1/2 inch).

c. Using slow, continuous pressure, flush wounds. wound Cleans all wall surfaces.
Caution: splashing sometimes
occur during this step.

d. Pinch off catheter just below syringe while Avoids contamination of sterile
keeping catheter in place.

e. Remove and refill syringe. Reconnect to catheter solution. Indicates wound clear of
and repeat until solution draining
into basin is clear.
debris.

10. Obtain cultures, if ordered, after cleaning with Types of wound culture obtained depends on
nonbacteriostatic saline. resources availability in facility. The three most
common types of wound specimens are tissue
biopsy, needle aspiration wound fluid, and swab
technique.

11. Assess type of tissue in wound bed and Identifies wound healing progress and
periwound skin. determines if wound has increased in size.

12. Dry wound edges with gauze. Prevents maceration of surrounding tissue
caused by excess moisture.

13. Apply appropriate dressing. Maintains protective barrier and healing

environment for wound.

14. Remove gloves and, if worn, mask, goggles and Prevents transfer of microorganism.
gown.

15. Dispose of equipment and soiled supplies. Reduce transmission of microorganism

Perform hand hygiene.

16. Help patient to comfortable position.

EVALUATION: SCRIPT

1. Inspect dressing periodically. Do you feel any untoward signs and

Rationale: symptoms concerning your wounds?
Determines patient’s response to wound irrigation
and need to modify plan of care. I will assess your wound site so please tell
me if you feel pain during the assessment

2. Determine patient’s level of pain How do you feel right now? Do you feel any
Rationale: pain? From the scale of zero as the lowest pain
Patient’s pain should not increase as result of scale and 10 is the highest.
wound irrigation

3.Observe for presence of retained irrigant.

Rationale:
 Retained irrigant is medium for bacterial
growthand subsequent infection.

SKILL ASSESSMENT Able to perform Able to perform Unable to REMARKS

(4-5) with assistance perform
(2-3) (0-1)
1. Identify patient using two
identifiers
2. Review medical record for
information about size and
location of wound
3. Assess patient’s level of
comfort using a scale of 0-10.
4. Review orders for dressing
change procedure
5. Assess patient for allergies
to wound cleansing agents or
tape

6. Assess patient’s and

family’s knowledge of purpose
and steps of dressing change

7. Assess for risk of delayed

or poor wound healing
8. Explain procedure to patient
and instruct him or her not to
touch wound area or sterile
supplies

9. Position the patient

comfortably and drape with
blanket to expose only wound
site.
10. Plan dressing change 30-
60 minutes following
administration of analgesia.
11. Close room door or pull
bedside curtains. Perform
hand hygiene and apply
gloves
12. Position patient
comfortably and drape only to
expose wound site.
13. Place disposable bag
within reach of work area.

14. Remove tape: gently push

skin away from tape while
pulling adhesive from skin.

15. With gloved hand carefully

remove gauze dressings one
layer at a time, taking care not
to dislodge drains or tubes.

a. If dressing sticks on dry

dressing, moisten with saline
and the remove

16. Observe for wound for

color, edema, drains and
exudates and amount of
drainage on dressing
17. Fold dressings with
drainage contained inside
and remove gloves inside out.
With small dressings remove
gloves inside out over
dressing. Dispose of gloves
and soiled dressings in
disposable bag. Perform hand
hygiene
18. Open sterile dressing tray
or individually wrapped sterile
supplies. Place on bedside
table and apply clean gloves
19. Clean wound with solution.
Using gauze or antiseptic
swab, clean from least
contaminated area, which is
the incision and surrounding
skin. Dry area. Remove and
dispose of gloves and perform
hand hygiene.

20. Apply dressing

a. Dry dressing
1. Apply clean or
sterile gloves.
2. Inspect wound for
appearance, drains, drainage
and integrity.
3. Apply sterile, loose woven
gauze (4x4, 2x2) dry
dressing, covering wound.
Apply additional gauze as
needed.
21. Secure dressing
a. Tape: apply tape 2.5-5 cm
(1-2 inches) beyond dressing,
use non allergic tape to
secure dressing in place.

b. Montgomery ties
1.Openby exposing adhesive
surface
2. Place ties on opposite
sides of dressing.
3. Place adhesive directly on
skin or apply a solid skin
barrier to skin and
secure end of tape on
skin barrier.
4. Secure dressing by lacing
ties across it
c. For dressings on
extremity, secure dressing
with rolled gauze or elastic
net.

22. Remove gloves and

dispose of them in bag.
Remove any mask, eyewear
or gown
23. Write date and time
dressing applied in ink on
tape securing dressing
24. Help patient to
comfortable position.
25. Dispose of supplies and
perform hand hygiene
26. Inspect condition of
wound and any drainage.

27. Ask patient to rate level

of pain during and after the
procedure.

28. Inspect condition of

dressing and note any
observable drainage every
shift.

WOUND IRRIGATION

1. Identify patient using

two identifiers (e.g., name
and birthday or name and
medical record number)
according to agency policy.

2. Assess patient’s level

of pain.

3. Review medical
record for health care
provider’s prescription for
irrigation of open wound and
type of solution
4. Review medical record for
signs and symptoms related
to patient’s open wound.

a. Extent of
impairment of skin
integrity, including
size of wound.
b. Verify number and types
of drains present.
c. Drainage from wound
(amount and color) (Amount
can be measured by part of
dressing saturated on
interms of quantity
d. Odor (must state whether
or not there is odor)
e. Wound tissue color
f. Consistency of drainage
g. Culture reports
h. Condition of dressing: dry
and clean; evidence of
bleeding, profuse drainage

PLANNING
1. Explain procedure of
wound irrigation and
cleaning how you will
prepare patient.
2. Administer prescribed
analgesic 30-60 minutes
before starting wound
irrigation procedure.
3. Position patient to access
wound for easy irrigation.
a. Position comfortably so
wound is vertical to
collection basin, which
permits gravitational flow of
irrigating solution through
wound and into collection
receptacle.
b. Place container of
irrigant/cleaning solution in
basin of hot water to warm
solution to body temperature.
c. Place padding or extra
towel in bed

IMPLEMENTATION
1. Perform hand hygiene.

2. Form cuff on waterproof

bag and place it near bed.
3. Close room door or bed
curtains.
4. Apply gown, mask, goggles
if needed.
5. Apply clean gloves and
remove soiled dressing and
discard waterproof bag.
Discard gloves and perform
hang hygiene.
6. Prepare equipment: open
sterile supplies
7. Put on clean or
sterile gloves

8. To irrigate wound
with wide opening:

a. Fill 35-ml syringe with

irrigating solution.
b. Attach soft 19-gauge
Angio catheter.
c. Hold syringe tip 2.5 cm
(1 inch) above upper end
of wound and over area
being
cleaned.
d. Using continuous
pressure, flush wound:
repeat Steps 8a, b, and c
until solution
draining into basin is clear.

9. To irrigate deep
wound with very small
opening:

a. Attach soft 19-gauge

Angio catheter to filled
irrigating syringe.
b. b. Gently insert tip of
catheter into wound and pull
out about 1 cm (1/2 inch).
c. c. Using slow,
continuous pressure, flush
wounds. Caution: splashing
sometimes
occur during this step.
d. Pinch off catheter just
below syringe while keeping
catheter in place.
e. e. Remove and refill
syringe. Reconnect to
catheter and repeat until
solution draining
into basin is clear.
10. Obtain cultures, if
ordered, after cleaning with
nonbacteriostatic saline.
11. Assess type of tissue in
wound bed and periwound
skin
12. Dry wound edges with
gauze.

13. Apply appropriate

dressing.
14. Remove gloves and, if
worn, mask, goggles and
gown.
15. Dispose of equipment
and soiled supplies. Perform
hand hygiene.
16. Help patient to
comfortable position.
EVALUATION
1. Inspect dressing
periodically.
2. Determine patient’s level of
pain
3.Observe for presence
of retained irrigant.

REMARKS:
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